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celebrated geniuses in music, literature, theater, science, and politics were probably so “affl icted.” Others may experience
Bipolar Affective Disorder
long and intense depressions with only fl eeting episodes of a near-normal mood in between.
DSM-IV-TR divides bipolar disorder into four categories de-pending on the particular presentation. Bipolar I disorder is characterized by the occurrence of one or more manic or mixed
Related Terms
episodes, and depressive episodes may have occurred. Bipolar II
disorder is characterized by the occurrence of major depressive
episodes and hypomanic episodes. Cyclothymic disorder features
symptoms of hypomania and depression. Bipolar disorder, NOS (not otherwise specifi ed) is applied when symptoms do not
Medical Codes
clearly fall into any of the above categories.
• ICD-9-CM: 296, 296.4, 296.7
There is no single proven cause but it is thought to be a bio-
• ICD-10: F31.6, F31.7, F31.8
chemical problem related to lack of stability in transmission of
Defi nition
nerve impulses in the brain. This biochemical imbalance makes individuals with bipolar affective disorder more vulnerable to
Although bipolar affective disorder is classifi ed as a mood
disorder, the condition also affects cognition and behavior and frequently is complicated by psychotic symptoms (e.g.,
Risk: Bipolar affective disorder can present at virtually any
delusions, hallucinations, disorganized thinking). As many as
point across the life span. Data from the National Institute of
two-thirds of bipolar patients have a lifetime history of psycho-
Mental Health Epidemiologic Catchment Area (ECA) study
sis (Rivas-Vasquez). Bipolar affective disorder is a disturbance
discovered a median age of onset of 18. Bipolar affective disorder
of the brain characterized by major mood swings. When the
is a heritable biologic illness with occurrence higher in relatives
condition is severe, an individual may experience episodes of
of individuals with the condition. The presentation and course
extreme highs (mania) and extreme lows (depression) several
of bipolar disorder differs between women and men, depending
times a year. These episodes may last between a few days to
on the subtype of the condition. The onset of bipolar disorder
a few months. The DSM-IV-TR (Diagnostic and Statistical
tends to occur later in women than men, and women more
Manual of Mental Disorders, 4th Edition, Text Revision) adds
often have a seasonal pattern of the mood disturbance. Women
the suffi x “rapid cycling” to the diagnosis of bipolar disorder if
experience depressive episodes, mixed mania, and rapid cycling
the individual experiences four or more mood episodes (depres-
sion, manic, or mixed) during a twelve month period. The suffi x
Incidence and Prevalence: Estimates of the lifetime prevalence
“with seasonal pattern” applies to bipolar affective disorder when
of bipolar affective disorder from two major community surveys
the depressive component is related to the season of the year
of the general population of the US vary from 1.0% to 1.6%
In mania, the essential feature is brain overactivity. Thought
Diagnosis
processes are accelerated, mood is generally elevated, the need
History: The diagnosis can be made based on history or by
for sleep is greatly reduced or absent, and energy seems limitless.
psychiatric evaluation during a manic phase. During a depres-
Unfortunately, thinking becomes less critical and often illogi-
sive phase, observation must be augmented by history to dif-
cal. Insight into the condition may be missing entirely as is the
ferentiate between bipolar and major depressive disorders. Even
ability to discriminate between rational and faulty thinking.
with a careful history, the diagnosis may prove to be incorrect
Consequently, through impaired judgment, individuals tend
in two-thirds of individuals and must be considered a working
to greatly overestimate their abilities, act impulsively, and may
completely ignore social conventions and often behave in a grossly inappropriate or outlandish manner. Psychosis may be
A good medical history is initially necessary to exclude the use
present with delusions of grandeur such as being the President
of steroids, thyroid supplements, other prescription medica-
or Jesus Christ. The periods of depression are also dangerous
tions, or nonprescription “street” drugs such as amphetamines
particularly when they occur in the wake of a manic episode.
The frantic energy, racing thoughts, exuberance, and optimism
The DSM-IV-TR spells out specifi c criteria for the diagnosis of
characteristic of mania is suddenly replaced by morbid preoc-
a manic episode. In general, the mood disturbance must cause
“marked impairment” in social or occupational functioning and
Bipolar illness presents in many variations both in terms of the
must not be due to a medical condition, effect of a medication,
severity of mood swings and the rate at which they change. Some
or drug intoxication. Three of the following symptoms must be
individuals with sustained periods of a milder form of mania
present for a minimum of 1 week: infl ated self-esteem, decreased
known as hypomania may productively harness the abundance
need for sleep, more talkative than usual, racing thoughts, easily
of energy and ideas in very creative ways. Many of our most
distracted, increased purposeful activity, and excessive involve-
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ment in risky endeavors with potential adverse consequences.
Unfortunately, many individuals choose not to take the medica-
There may be a history of confl icts at work; legal, fi nancial and
tions as directed and as a result relapse into mania. Noncompli-
family problems; spending sprees or extravagant purchases;
ance with medications is sometimes due to unpleasant side ef-
business misadventures; extramarital affairs; impulsive travel;
fects. In other cases, however, it is clearly a matter of preference.
or turbulent social relations. Psychosis may be present with
Many bipolar individuals so enjoy the “high” feelings associated
delusions of grandeur such as the individual thinking that he
with the mania that they do not want to give it up. Because
or she is the President or Jesus Christ.
these medications are potentially damaging and prescribed for
During depressive episodes, the individual has feelings of
life, periodic laboratory testing is necessary.
sadness, hopelessness, and loss of interest in life activities or
Occasionally, the medications prove to be ineffective in bringing
relationships. These symptoms are present for at least 2 weeks
a manic episode under control. In this instance, electroconvul-
and make it diffi cult for the individual to function. They are
sive therapy (ECT) may control the acute episode, and may also
associated with at least four of the following: thoughts of death
be continued on a regular basis as a preventive measure against
or suicide, trouble sleeping or sleeping too much, poor appetite
or overeating, diffi culty concentrating and making decisions,
During manic episodes, there is a high-risk of accidental death.
feeling slowed down or too agitated to sit still, feeling worthless
Psychiatric hospitalization is frequently necessary to ensure the
or guilty with very low self esteem, and loss of energy or feeling
individual’s safety. The periods of depression are also dangerous,
tired all the time. Hearing voices or seeing things that aren’t
particularly when they occur in the wake of a manic episode,
there (auditory or visual hallucinations) or believing things
and may also require hospitalization. When antidepressants
that aren’t true (delusions) may accompany severe depressive
must be used, they should be given with a mood stabilizer to
prevent the individual from rebounding into hypomania. As
Physical exam: When the illness is fi rst noticed, a thorough
with most serious psychiatric illnesses, there is no cure. Medica-
exam should be performed to exclude physical causes such as
tion-assisted remissions are common, however, and may result
hyperthyroidism or neurological disease. Observation of the
individual’s orientation, dress, mannerisms, behavior, and con-
Pharmacotherapy is the primary treatment for bipolar affective
tent of speech provide essential signs to diagnose the illness. A
disorder, but many authorities recommend augmentation with
psychiatric evaluation should be done as soon as possible if a
various psychotherapeutic techniques. A primary goal of psycho-
therapy is reducing the high rate of medication discontinuation
Tests: Psychological testing such as the Minnesota Multiphasic
and overall noncompliance with the pharmacological regime.
Personality Inventory (MMPI-2) may aid in diagnosis if the
Other risk factors associated with mood instability also serve as
evaluation is made while the individual is in a near-normal mood
psychotherapy objectives. Psycho-educational classes, support
and the history is merely suggestive of bipolar illness. Laboratory
groups, and cognitive behavioral therapy groups lend themselves
tests should be done to rule out endocrine or metabolic distur-
well to adjunctive treatment of bipolar disorder, and spouse and
bances, or to monitor compliance if medications are already
family involvement can also be helpful. If an individual has a
being prescribed. As low blood levels of thyroid hormone are
dual diagnosis of mental illness and addiction, integrated dual
more common in individuals with rapid cycling than in other
diagnosis treatment may be helpful. This type of treatment
individuals, thyroid function tests should be done before, during
focuses on treating both diagnoses simultaneously by the same
and after treatment as medically indicated. Urine screens for
clinician or team of clinicians on a personalized basis.
licit and illicit drugs should be done to rule out drugs as factors contributing to the symptom picture.Prognosis
Individual outcomes vary greatly. During manic episodes, there
Treatment
is a high-risk of accidental death. Manic episodes can last any-
Medications are the mainstay of treatment, with psychotherapy
where from a few days to several months. With medications, the
a useful supportive tool. Medications consist primarily of mood
duration of manic episodes can be shortened signifi cantly but
stabilizers, such as lithium and valproic acid, that moderate
may still involve a month or more of intensive therapy, often on
the intensity of mood swings. The most extensively studied
an inpatient basis. Suicide attempts may complicate a depressive
mood-stabilizing agent is lithium and often the fi rst choice of
episode. Individuals with bipolar affective disorder have at least
treatment for bipolar affective disorder. Anticonvulsant medi-
a 15-fold greater risk of suicide than the general population. Left
cations, such as valproic acid, lamotrigine, and carbamazepine,
untreated, the illness becomes worse with time and may end
have increasingly been employed as important pharmacothera-
up being very resistant to treatment, rendering the individual
peutic alternatives, either as a primary pharmacotherapy or as
incapable of working or having normal relationships.
augmentation to lithium. Antipsychotic medications such as
Bipolar disorder was the sixth leading cause of disability world-
olanzapine and clozapine may be used. Recently the FDA has
wide in 1990 (Keck). Morbidity resulting from the illness is not
approved risperidone and quetiapine as primary and as adjunct
limited to acute episodes of mania or depression. Full recovery
therapies for the treatment of bipolar affective disorder. In Au-
of functioning often lags behind remission of symptoms.
gust, 2004 the FDA approved ziprasidone for manic and mixed (high and low) episodes.
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In general, bipolar disorder cannot be cured but the symptoms
Return to Work
can usually be controlled. Individuals can frequently lead normal
Accommodations depend on the type of work required. Stressful
and productive lives. In less fortunate cases, the illness may be
events and/or lack of sleep may increase risk of igniting a manic
nearly impossible to arrest or control and results in permanent
episode. Rotating shifts should be avoided. Regular daytime
total or near-total disability. Early in the course of the disease,
hours may be necessary for signifi cant periods of time. High-
spontaneous remissions of up to several years duration are some-
pressure jobs or jobs with deadlines requiring the individual
times seen. This “honeymoon period” may delay diagnosis or
to work extremely long hours over extended time periods are
convince the individual that the diagnosis was incorrect.
also not recommended. Leaves of absence may be necessary
Up to 60% of individuals with bipolar disorder obtain some relief
from lithium and other mood stabilizers, but the response rate is lower in those with rapid cycling (Hillard).Failure to RecoverDifferential DiagnosesRegarding diagnosis:• Was diagnosis confi rmed? Based on what criteria?
• Even if a clear history of bipolar illness is present, have the
history, physical exam, and testing excluded other possible
• Does medication and drug history reveal use of steroids,
thyroid supplements, other prescription medications, or
Specialists
street drugs that could cause similar symptoms?
• Is there evidence of rapid cycling (defi ned as four or more
episodes of mania, excitement with moderate behavior
Comorbid Conditions
change, or depression in any 12-month period)? Because it
responds poorly to treatment, could failure to improve be
• Because low blood levels of thyroid hormone are more
common in individuals with rapid cycling than in other bipolar individuals, were thyroid function tests performed
Complications
Complications depend on the severity of the illness and the
• Is there a history or evidence of current substance abuse
presence of impaired reality testing (psychosis). The most
that makes an individual more prone to cycling with
serious complication is accidental death or suicide. Other
consequences of impaired judgment may include confl icts at
Regarding treatment:
work; legal, fi nancial and family problems; spending sprees or
• Does individual fi t criteria for rapid cycling?
extravagant purchases; business misadventures; extramarital
• Is thyroid replacement therapy warranted based on thyroid
affairs; impulsive travel; and turbulent social relations. Lifelong
substance abuse affects up to 50% of bipolar individuals and may
• Has use of antidepressants precipitated hypomania,
warranting discontinuation or change in medications?
Factors Infl uencing Duration
• Is there current evidence of substance abuse? How
A history of episodes of relatively short duration, good response
successfully is the substance abuse being addressed?
to medications, and long periods of normal mood predict the
• What plan is in place to ensure compliance with
shortest period of disability. Substance abuse, noncompliance
with medications, psychosis, and a history of lengthy hospital-
• If combinations of medications and psychotherapy have
izations tend to delay recovery. Serious episodes of mania may
not provided adequate relief, is electroconvulsive therapy
take 1 to 2 months and occasionally longer to be controlled
suffi ciently to allow return to work. Some individuals may be
• If self-harm or personal neglect put individual at risk, is
unable to maintain stable employment largely because of sub-
stance abuse or problems getting along with others.Regarding prognosis:• Does individual display any tendency toward self-harm or Length of Disability
suicide? What preventive safeguards are in place?
Psychotherapy and pharmacotherapy, bipolar affective
• Is illness interfering with self-esteem, friendships, social
disorder.
• Would individual benefi t from one-on-one psychotherapy
DURATION IN DAYS
based on interpersonal, cognitive, or behavioral
• Is individual involved in a support group?
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• If no improvement occurs after 6 to 8 weeks or if symptoms
Keck, P. E., et al. “Advances in the Pathophysiology and Treatment
have worsened, is it time to try another treatment approach
of Psychiatric Disorders: Implications for Internal Medicine.” Medical
or another medication? Get a second opinion from another
Clinics of North America 85 3 (2001): 645-661.
Rivas-Vasquez, R. A., et al. “Current Treatments for Bipolar Disorder: A Review and Update for Psychologists.” Professional Psychology: Research Cited Referencesand Practice 33 2 (2002): 212-223.
Frances, Allen, ed. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric
Tennen, Melissa. “Bipolar By-Product: Substance Abuse.” Health A to Z. Apr. 2004. 8 Dec. 2004 <http://www.healthatoz.com>.
Hillard, Erika Bukkfalvi. Manic-Depressive Illness. New Westminster,
Thase, M. E., M. Bhargava, and G. S. Sachs. “Treatment of Bipolar
B.C.: Royal Columbian Hospital, 1992. Internet Mental Health. Phillip
Depression: Current Status: Continued Challenges, and the STEP-BD
W. Long. 8 Dec. 2004 <http://www.mentalhealth.com/book/p40-ma01.
Approach.” Psychiatric Clinics of North America 26 2 (2003): 495-518.
National Center for Biotechnology Information. National Library of Medicine. 8 Dec. 2004 <PMID: 12778844>.
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PLEASE COMPLETE THE FOLLOWING CONFIDENTIAL INFORMATION PATIENT REGISTRATION IF YOUR CHILD S LAST NAME AND/OR ADDRESS ARE NOT THE SAME AS YOURS, FILL IN THE TOP BOX ALSOPERSON FINANCIALLY RESPONSIBLE FOR ACCOUNTRELATIONSHIP TO PATIENT SOCIAL SECURITY NO. IS ANOTHER MEMBER OF YOUR FAMILY OR RELATIVE A PATIENT AT OUR OFFICE? YOU WERE REFERRED TO US BY YOUR FORMER ADDRESS PERSON TO